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ATI Nursing Specialty

A nurse in a clinic is caring for a client who came to be tested for tuberculosis (TB) after a close family member tested positive. The nurse should know that which of the following is a diagnostic tool used to screen for TB?

    A. Sputum culture for acid-fast bacillus (AFB)

    B. Mantoux skin test

    C. BCG vaccine

    D. Chest X-ray

Correct Answer: Mantoux skin test
Rationale: The Mantoux skin test, also known as the tuberculin skin test, is a diagnostic tool used to screen for tuberculosis (TB). It involves injecting a small amount of tuberculin under the top layer of the skin on the forearm and then checking for a reaction within 48-72 hours. This test helps identify individuals who have been exposed to the TB bacteria. Sputum culture for acid-fast bacillus (AFB) is used to confirm TB diagnosis in individuals suspected of having active TB. The BCG vaccine is used to prevent severe forms of tuberculosis in high-risk individuals but is not a diagnostic tool. While a chest X-ray can show signs of active TB disease, it is not a primary diagnostic tool for screening purposes.

A nurse in a clinic is caring for a client who came to be tested for tuberculosis (TB) after a close family member tested positive. The nurse should know that which of the following is a diagnostic tool used to screen for TB?

  • A. Sputum culture for acid-fast bacillus (AFB)
  • B. Mantoux skin test
  • C. BCG vaccine
  • D. Chest X-ray

Correct Answer: Mantoux skin test
Rationale: The Mantoux skin test, also known as the tuberculin skin test, is a diagnostic tool used to screen for tuberculosis (TB). It involves injecting a small amount of tuberculin under the top layer of the skin on the forearm and then checking for a reaction within 48-72 hours. This test helps identify individuals who have been exposed to the TB bacteria. Sputum culture for acid-fast bacillus (AFB) is used to confirm TB diagnosis in individuals suspected of having active TB. The BCG vaccine is used to prevent severe forms of tuberculosis in high-risk individuals but is not a diagnostic tool. While a chest X-ray can show signs of active TB disease, it is not a primary diagnostic tool for screening purposes.

A nurse is caring for a client who has active pulmonary tuberculosis (TB). The client is on airborne precautions and is being treated with multidrug therapy. A chest x-ray is scheduled for the client. Which of the following is not a precaution the nurse should take to safely transport the client to x-ray?

  • A. Ask the x-ray technician to come to the client's room to perform a portable x-ray.
  • B. Have the client wear a mask.
  • C. Notify the x-ray department that the client is on airborne precautions.
  • D. Wear a filtration mask and gloves for protection against the client's microorganisms.

Correct Answer: Ask the x-ray technician to come to the client's room to perform a portable x-ray.
Rationale: The correct answer is to ask the x-ray technician to come to the client's room to perform a portable x-ray. This option minimizes the risk of exposing other individuals to the client's infectious microorganisms during transport. Having the client wear a mask (Choice B) and notifying the x-ray department about airborne precautions (Choice C) are crucial precautions to prevent the spread of infection. Additionally, wearing a filtration mask and gloves (Choice D) is essential for the nurse's protection when in direct contact with the client, but it is not directly related to transporting the client to the x-ray department.

A nurse in a community health center is assessing the results of the purified protein derivative (PPD) testing she performed to screen for tuberculosis (TB). She interprets which of the following results as positive for a 6-year-old client with no risk factors for TB?

  • A. 4-mm erythema
  • B. 5-mm induration
  • C. 10-mm wheal
  • D. 15-mm induration

Correct Answer: 15-mm induration
Rationale: The correct answer is D: 15-mm induration. In PPD testing, an induration (hardened raised area) of 15 mm or more is considered positive for TB in individuals with no risk factors. Choices A, B, and C are incorrect because an erythema of 4 mm, induration of 5 mm, or wheal of 10 mm are not indicative of a positive TB test result in a low-risk individual. Therefore, the interpretation of a 15-mm induration would lead the nurse to consider the test positive for TB in this case.

A nurse is caring for a client who came to the emergency department reporting chest pain. The provider suspects a myocardial infarction. While waiting for the laboratory to report the client's troponin levels, the client asks what this blood test will show. The nurse should explain that troponin is

  • A. an enzyme that indicates damage to brain, heart, and skeletal muscle tissues.
  • B. a protein whose levels reflect the risk for coronary artery disease.
  • C. a heart muscle protein that appears in the bloodstream when there is damage to the heart.
  • D. a protein that helps transport oxygen throughout the body.

Correct Answer: a heart muscle protein that appears in the bloodstream when there is damage to the heart.
Rationale: The correct answer is that troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart. Troponin is a specific marker for heart muscle damage, particularly seen in conditions like myocardial infarction. Choice A is incorrect as troponin is not an enzyme that indicates damage to brain and skeletal muscle tissues. Choice B is incorrect as troponin is not a protein whose levels reflect the risk for coronary artery disease; it indicates heart muscle damage. Choice D is incorrect as troponin is not a protein that helps transport oxygen throughout the body; its presence in the bloodstream is specific to heart muscle damage.

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